45-year-old male with multiple CAD risk factors presented to OSH on November 6, 2020 with unstable angina and positive ETT. A Cardiac Cath on November 9, 2020 revealed extensive 3V CAD: 100% mid LAD, 90% D2, 70% proximal LCx, 100% LCx-OM1, 100% mid RCA with LVEF = 60% and SYNTAX Score of 50. After Heart Team discussion, CABG was recommended, but declined by the patient. Patient continued on optimal medical therapy, but remains in CCS angina Class II. Patient is now planned for high-risk complex PCI of LAD/D1 and LCx/OM1 with Impella on standby for hemodynamic deterioration.